Patient-specific fracture fixation instrumentation and method

ABSTRACT

An instrument for internal bone fracture fixation includes a shaft having a distal portion and a patient-specific bone holder coupled to the distal portion. The bone holder has a three-dimensional curved and patient-specific bone engagement surface designed during a preoperative plan based on a medical scan of a patient to match and conform to an outer surface of a bone fragment of the patient in only one position.

FIELD

The present teachings relate to various patient-specific instruments for reducing fractures and facilitating internal fixation.

INTRODUCTION

The present teachings provide various methods and instruments and implants for reducing bone fractures and providing internal fixation. More specifically, the present teachings provide methods and devices to assemble, reduce and fix various bone fragments of a bone.

Three-dimensional images of the corresponding anatomy of the patient can be reconstructed using medical scans. Imaging methods can be used to design patient-specific fragment-holding components of reduction instruments during a preoperative plan. Intraoperatively, the fragment-holding components can capture the fragments, which can be brought together with a reduction instrument to reconstruct the pre-fracture bone geometry and fix the fracture with patient-specific fixation devices, such as plates with patient-specific geometry and other fasteners or fixator implant components.

SUMMARY

This section provides a general summary of the disclosure, and is not a comprehensive disclosure of its full scope or all of its features.

The present teachings provide an instrument for internal bone fracture fixation including an elongated shaft having a distal portion and a patient-specific bone holder coupled to the distal portion. The bone holder has a three-dimensional curved and patient-specific bone engagement surface designed during a preoperative plan based on a medical scan of a patient to match and conform to an outer surface of a bone fragment of the patient in only one position.

In some embodiments, an instrument for internal bone fracture fixation includes a first elongated shaft having a first arm with a first distal portion and a second shaft having a second arm with a second distal portion. The second shaft is pivotably coupled to the first shaft. A first patient-specific bone holder is coupled to the first distal portion. A second bone holder is coupled to the second distal portion. In some embodiments one or both of elongated shafts are telescopic.

The present teachings also provide a patient-specific implant having a bone-engagement surface designed during the preoperative plan based on a medical scan of the patient to match and conform to an outer surface of a bone fragment of the patient in only one position.

The present teachings provide a method for internal bone fracture fixation. The method includes engaging an inner three-dimensional surface of a bone holder with an outer surface of a bone fragment of a bone of a patient and moving the bone fragment to engage a fractured surface of the bone using a shaft connected to the bone holder. The method also includes passing a pin through a hole of the bone holder into the bone, removing the bone holder, and attaching a patient-specific bone-engagement surface of an implant to an outer surface of bone portion and the bone fragment.

Further areas of applicability will become apparent from the description provided herein. The description and specific examples in this summary are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustrative purposes only of selected embodiments and not all possible implementations, and are not intended to limit the scope of the present disclosure.

FIG. 1 is a computer-generated image of re-assembled bone fragments and patient-specific fixation members during a preoperative plan for a specific patient suffering a femoral bone fracture according to the present teachings;

FIG. 1A is a computer-generated image of a re-assembled bone fragment and patient-specific fixation member during a preoperative plan for a specific patient suffering a humeral bone fracture according to the present teachings.

FIG. 2A is a plan view of a customized instrument for fracture reduction shown with various patient-specific bone holders, according to the present teachings;

FIG. 2B is a detail of an exemplary removable connection for the bone holders of FIG. 2A;

FIG. 2C is an environmental perspective view of a customized instrument for fracture reduction shown in use according to the present teachings;

FIG. 3 is an environmental perspective view of customized instruments for fracture reduction shown in use according to the present teachings;

FIG. 4 is an environmental view of the internal fixation implants of the reduced fracture shown in the image of FIG. 1; and

FIG. 4A is an environmental view of the internal fixation implant of the reduced fracture shown in the image of FIG. 1A.

Corresponding reference numerals indicate corresponding parts throughout the several views of the drawings.

DETAILED DESCRIPTION

Example embodiments will now be described more fully with reference to the accompanying drawings. Example embodiments are provided so that this disclosure will be thorough, and will fully convey the scope to those who are skilled in the art. Numerous specific details are set forth such as examples of specific components, devices, and methods, to provide a thorough understanding of embodiments of the present disclosure. It will be apparent to those skilled in the art that specific details need not be employed, that example embodiments may be embodied in many different forms and that neither should be construed to limit the scope of the disclosure. In some example embodiments, well-known processes, well-known device structures, and well-known technologies are not described in detail.

The present teachings provide various methods, instruments and implants for reducing bone fractures and providing internal fixation for bone fractures. More specifically, the present teachings provide methods and devices to assemble, reduce and fix various bone fragments of a bone. Patient-specific fracture reduction instruments or instruments customized with removable patient-specific bone holders or other components, as well as patient-specific fixation plates are provided according to the present teachings and described below.

In the context of the present teachings, patient-specific instrument components and implants are generally configured to match the anatomy of a specific patient and are generally formed using computer modeling based on the patient's reconstructed three-dimensional anatomic image. The patient-specific instrument components have an engagement surface that is made to conformingly contact and match a three-dimensional image/model of the patient's bone surface (with or without cartilage or other soft tissue), by the computer-assisted image methods, as discussed below. In this respect, a patient-specific instrument component or implant can nestingly mate in only one position with the corresponding bone surface (with or without articular cartilage) of a bone fragment or a reduced fracture replicating an intact bone of the specific patient. The patient-specific instrument components can include custom-made (patient-specific) guiding formations, such as, for example, guiding holes for sutures, K-wires or for inserting pins or other fasteners in configurations determined by a surgeon-approved pre-operative plan.

The patient-specific components and other associated instruments and implants can be designed preoperatively using computer-assisted image methods based on three-dimensional images of the patient's knee anatomy reconstructed from MRI, CT, ultrasound, X-ray, or other three- or two-dimensional medical scans of the patient's anatomy and in some cases complemented with digital photography methods and/or anthropometry databases. Various CAD programs and/or software can be utilized for three-dimensional image reconstruction, such as software commercially available, for example, by Materialise US, Plymouth, Mich.

In the preoperative planning stage for a fracture reduction and fixation, imaging data of the relevant anatomy of a patient can be obtained at a medical facility or doctor's office, using one of medical imaging methods described above. The imaging data can include, for example, various medical scans of a relevant portion of the patient's anatomy, as needed for joint modeling, including images of all the bone fragments, the main bone and an equivalent intact bone, such as, for example, a right side femoral bone when a left side femoral bone is fractured. An initial preoperative plan can be prepared for the patient in image space and can include bone fragment reduction, implant selection and fitting, as well as designing patient-specific components, tools, and implants for the surgical procedure.

Various patient-specific instruments and pre-operative planning procedures are disclosed in commonly assigned and co-pending U.S. patent application Ser. No. 11/756,057, filed on May 31, 2007, U.S. patent application Ser. No. 12/211,407, filed Sep. 16, 2008; U.S. patent application Ser. No. 11/971,390, filed on Jan. 9, 2008, U.S. patent application Ser. No. 11/363,548, filed on Feb. 27, 2006; U.S. patent application Ser. No. 12/025,414, filed Feb. 4, 2008, U.S. patent application Ser. No. 12/571,969, filed Oct. 1, 2009, and U.S. patent application Ser. No. 12/955,361, filed Nov. 29, 2010. The disclosures of the above applications are incorporated herein by reference.

The various patient-specific instrument component discussed herein can be made of any biocompatible material, including metal or plastic. Generally, the patient-specific bone holders can be single use, disposable and made of lightweight materials, including polymers. The various patient-specific components described herein can be manufactured by various stereolithography methods, selective laser sintering, fused deposition modeling or other rapid prototyping methods. In some embodiments, computer instructions of tool paths for machining the patient-specific guides and/or implants can be generated and stored in a tool path data file. The tool path data can be provided as input to a CNC mill or other automated machining system.

The present teachings provide various methods and devices for reducing fractures and providing internal fixation customized for a specific patient and fracture. Various embodiments of customized instruments are illustrated in FIGS. 2A-3 and described below. A computer depiction of a computer-assisted preoperative plan is illustrated in FIG. 1 and discussed below.

FIGS. 1 and 1A illustrate a screen or display 52 of a computer terminal, laptop, tablet, smartphone or other computer-type device that can include standalone imaging software or provide online, mobile, cloud or other connectivity (including Ethernet, wired or wireless, Wi-Fi, 3G, 4G, etc.) to imaging software, such as, for example, the Surgicase® Connect, commercially available from Materialise US, Plymouth, Mich. Medical scans of the patient's bone and bone fragments are inputted through an data entry device or port 54 communicating with the computer device 50 or otherwise uploaded or accessed via cloud, internet or other secure connection by the imaging software.

Using the software, three- or two-dimensional images of the reconstructed bone and associated bone components and fragments are created for view and manipulation on the screen 54 during a preoperative plan for the specific patient. In FIGS. 1 and 1A, images of bone portions are referenced with the same numerals as the patient's actual bone portions, but with the added suffix “i” for differentiation without having to repeat “image of bone portion”.

The present teachings can be used for any bone, such as, for example a femoral bone, as illustrated in FIG. 1, a humeral bone, as illustrated in FIG. 1A or other bone. The same numerals are used to identify various bone portions in each bone 80, whether femoral or humeral or other bone. For example, in FIG. 1, the fractured bone is illustrated as a proximal femoral or hip bone 80 i. In FIG. 1A, the fractured bone is illustrated as a humeral bone 80 i. It is noted that the bone fragments are not necessarily in scale and that in similar situations, other types of surgical procedures may be indicated for the patient, such as total or partial joint replacement. The bone fragments are shown merely for the purpose of illustrating the versatility of the instruments according to the present teachings and not as indicating a surgical plan for the patient who suffers such fracture.

In the example of FIG. 1, first and second fragments 82 i and 86 i are fractured off the bone 80 i. Fragment 86 i is separated (wholly or partially) from a neck portion 88 i of the bone 80 i along a fracture surface 90 i (or weakened area 90 i) and fragment 82 i is separated (wholly or partially) from a trochanteric portion 84 i of the bone 80 i along a fracture surface 92 i (or weakened area 92 i). The fragments 82 i and 86 i are manipulated on the screen 52 using an input device (keyboard, mouse, stylus, or finger for touch screens) until the fragments 82 i, 86 i are brought in substantial contact with their mating portions 84 i, 88 i along the corresponding fracture surfaces 92 i and 90 i. The bone 80 i should appear substantially intact.

In some cases, a bone fragment may be missing (or no longer usable). In such cases, a patient-specific implant or non-custom implant or filler material, depending on the location and size of the missing fragment may be used. For example, a patient-specific implant 70 i can be designed to replace a corresponding missing bone fragment and attach to the underlying bone portion along a boundary surface 72 i that matches a corresponding fracture surface coinciding with 72 i in the illustration of FIG. 1. The patient-specific implant 70 i can be designed by various methods, including, for example, computationally extrapolating from the existing (assembled) bone fragments, selecting an implant from a database and morphing the selecting using anthropometric data together with the patient's own data, or creating a patient-specific implant 70 i from the mirror bone of the patient, for example, using images of the intact left femur if the right femur is fractured, or from preexisting images of the same bone before the fracture occurrence.

With continued reference to FIG. 1, when a small area of bone is missing or weakened, a filler material can be use to fill the corresponding area, creating a filer insert 74 i having a boundary 76 i that conforms to the remaining bone or bone fragment. The filler material can include inserts formed from bone, such as allografts, particulate matter (bone chips, bone powder), osteogenic materials, with or without porous metal or other frame-like constructs, such as Regenerex®, commercially available from Biomet Manufacturing Corp., Warsaw, Ind.

After all the bone fragments 82 i, 86 i and any bone implants 70 i, 74 i are brought together on the computer screen 52 to form the bone 80 i, one or more patient-specific internal fixation members 100 can be designed to match the corresponding three-dimensional geometry of the bone to permanently (intraoperatively and postoperatively) fix the fragments to the bone. In FIG. 1, two such fixation members 100A, 100B are illustrated. The numerals 100, 100A and 100B are used to denote both the actual fixation plates and their images on the computer screen 52. Each fixation member 100 can include a bone engagement undersurface 102 that is designed to conform and mate with the outer surface of bone and bone fragments that is designed to hold together and fix.

Referring to FIG. 1A, a single fragment 82 i is illustrated as fractured off the bone 80 i. Fragment 82 i is separated (wholly or partially) from a portion 84 i of the bone 80 i along a fracture surface 92 i (or weakened area 92 i). The fragment 82 i and the bone 80 i are manipulated on the screen 52 using an input device (keyboard, mouse, stylus, or finger for touch screens) until the fragment 82 i is brought in substantial contact with its mating portion 84 i along the corresponding fracture surface 92 i. The bone 80 i should appear substantially intact. In this exemplary embodiment, a single fixation member 100 is illustrated. As discussed above, the fixation member 100 includes a bone engagement undersurface 102 that is designed to conform and mate with the outer surface of bone and the bone fragment that it is designed to hold together and fix.

Referring to FIG. 2A, a forceps-like fracture reduction instrument 200 customized for a specific patient is illustrated. The reduction instrument 200 can be used to bring together the fragments of the bone and enable the attachment of the internal fixation members discussed in connection with FIG. 1. Another embodiment of a forceps-like fracture reduction instrument 200A customized for a specific patient is illustrated in FIG. 2C. Elements common to both embodiments are referenced by the same numerals.

Each of the reduction instruments 200, 200A can be either a dedicated patient-specific instrument or a standardized forceps instrument that can be fitted with removable and replaceable patient-specific components, such as patient-specific bone holders 220, 220A, 220B, 220C, 220D, 220E. The reduction instrument 200, 200A can include first and second elongated shafts or handles 203, 207 pivotably connected to a common pivot 208, such that the first and second handles 203, 207 can move between various configurations from a closed to an open position in a scissors-like manner relative to one another using respective finger loops 206. A locking mechanism 210, such as a ratchet bar connection, can connect the first and second handles 203, 207 and lock them at a selected position for holding the bone fragments against the bone to reduce the fracture

First and second arms 202, 204 extend respectively from the first and second handles 203, 207. The first and second arms 202, 204 can be either telescopically or fixedly coupled to the corresponding handles 203, 207. For example, in the embodiment 200 of FIG. 2A, the first arm 202 is telescopically moved along a bore 205 of the corresponding handle 203, while the second arm 204 is fixedly connected to the second handle 207. In the embodiment 200A of FIG. 2C, both first and second arms 202, 204, can move telescopically along corresponding bores 205 of the first and second handles 203, 207. Allowing telescopic movement of one or both arms 202, 204 is optional. Such movement can be restricted or locked using, for example, a set screw, or alternatively, both arms 202, 204 can be fixedly attached to their corresponding handles 203, 207. The distal portion of each of the arms 202, 204 can be curved with corresponding concave surfaces facing one another to create additional space therebetween for capturing bones of different dimensions. In some embodiments, the shape and dimensions of the first and second arms 202, 204 can also be patient-specific and designed during the preoperative plan. The distal portion of the arms 202, 204 can terminate at either a patient-specific bone holder 220 or at a non-custom end support or non-custom bone holder 211, as shown in FIG. 2A in connection with the second arm 204. In the embodiment of FIG. 2C, both arms 202, 204 are coupled to patient-specific bone holders 220 (220D, 220E).

With continued reference to FIGS. 2A-2C, in some embodiments, the bone holders 220 can be fixedly (rather than removably) coupled to the corresponding first and second arms 202, 204, such that the entire reduction instrument 200, 200A is patient-specific and disposable after use. In such embodiments, the length and shape of the corresponding first and second arms 202, 204 can also be designed for the specific patient. Telescopic motion of one or both arms 202, 204 may be optionally provided, as illustrated in FIG. 2A by double arrow A.

In other embodiments, the patient-specific bone holders 220 can be removably coupled to the corresponding arms 202, 204, such that new patient-specific holders can be designed and manufactured for each patient, while the remaining portion of the reduction instrument 200, 200A can be sterilized and re-used with the new patient-specific bone holders 220. Each patient-specific bone holder 220 has an inner or bone-engaging surface 230, which is generally a three-dimensional curved surface designed during the preoperative plan to closely match, as mirror or inverse image, the outer surfaces of the corresponding bone fragments and/or bone portions. The bone holder 220 is designed to have a surface and size sufficient to cap the bone fragment (or fragments) and/or a bone portion and securely hold the bone fragment/portion in a cup-like fashion. Various removable patient-specific bone holders 220 are illustrated in FIGS. 2A and 2C and referenced with the additional numerals 220A, 220B, 220C, 220D and 220E. The removable bone holders 220 can be coupled to a distal portion 212 of a corresponding arm using any type of removable or quick coupling connection. An exemplary connection is illustrated in FIG. 2B in the form of snap-fit connection, in which two protrusions or ball detents 214 on the distal portion 212 can snap through holes 224 in a channel or U-shaped extension 222 of the bone holder 220.

Referring to FIG. 2C, the reduction instrument 200A is illustrated with two patient-specific bone holders 220 (220D, 220E) and in use with a bone 80 having two bone fragments 82 and 86 corresponding to the images shown in FIG. 1. The reduction instrument 200A is used to grasp the fragments 82, 86 and bring them in engagement with the corresponding bone portions 82, 86 of the bone. Although a bone with only two fragments 82, 86 is illustrated, it should be appreciated that each bone holder 220 can be designed to engage and hold more than one bone fragment or a bone fragment and a portion of the bone in a patient-specific engagement. Additionally, more than one reduction instrument 200, 200A can be used to engage remaining bone fragments that are contiguous. Alternatively, after a first set of fragments is reduced, the original patient-specific holders 220 for those bone fragments/bone portions can be removed and the same reduction instrument 200, 200A can be fitted with one or two patient-specific bone holders 220 designed for the additional bone fragments.

In some embodiments, and as illustrated in FIG. 2C, a stabilizer 250 can be provided. The stabilizer 250 can be coupled to an extension 254 extending from the pivot that connects the handles 203, 207. The stabilizer 250 can include, for example, a shaft 256 slidably passing through a hole 252 of the extension 254 and lockable in a desired position with a set screw or other fastener. The distal end of the shaft 256 can be removably or fixedly connected to a stabilizing support 258 for engaging the bone during the fracture reduction procedure. The removable connection can be, for example, similar to the one illustrated in FIG. 2A for the patient-specific bone holders 220.

After the bone fracture has been reduced using one of the fracture reduction instruments 200, 200A, as discussed above, the bone fragments 82, 86 can be stabilized in the reduced configuration on the bone 80 using temporary or permanent fasteners, such as pins or K-wires 221 through one or more holes 223 on the patient-specific holders 220, as shown in FIG. 2C. With the fragments 82, 86 held against the bone 80, the patient-specific plates 100 (100A, 100B) are attached with bone fasteners 110 on the bone, as illustrated in FIG. 4, and as prepared during the preoperative plan.

Referring to FIG. 3, additional embodiments of fracture reduction instruments 300 are illustrated. In this embodiment, the instrument 300 can be a shaft 304 with a gripping handle 302. The shaft 304 can have a distal portion 308 which can be integral to the shaft 304, or telescopically coupled to the shaft 304, as illustrated in FIG. 3, wherein same numerals are used for elements common to those described above for the fracture reduction instruments 200, 220A. The distal portion 308 of the reduction instrument 300 can be removably coupled to a patient-specific bone holder 220 (220F, 220G), as described above in connection with FIGS. 2A-2C. One or several reduction instruments 300 can be used during the procedure by coupling different bone holders 220 to different shafts 304 or using the same shaft 304 with different bone holders 220F, 220G sequentially. In the illustration of FIG. 3, the neck fragment 86 may be brought in contact with the remaining neck portion 88 and secured with K-wires 223 through holes 221 of the corresponding bone holder 220F. The reduction instrument 300 and bone holder 220F can then be removed and the bone holder 220F replaced with the bone holder 220G for bringing the trochanteric fragment 82 in contact with the trochanteric portion 84. As discussed above, either the same shaft 304 or separate shafts 304 can be used with the removable bone holders 220F, 220G. In some embodiments, a stabilizing member 306 may be coupled to the shaft 304 for engaging and stabilizing the bone 80 for fixation with the K-wires 223. The supporting member 306 can be slidably coupled to the shaft 304 through a hole 320 in the supporting member 306 and lockable in a desired position with a set screw or other fastener 322.

The reduction instruments 200, 300 can be similarly used for reducing the fracture 92 of the humeral bone 80 and securing the fragment 82 with a patient-specific fixation plate 100. According to the present teachings, removable and patient-specific bone holders 220 can be provided for the particular fracture and bone of the specific patient.

The foregoing description of the embodiments has been provided for purposes of illustration and description. It is not intended to be exhaustive or to limit the disclosure. Individual elements or features of a particular embodiment are generally not limited to that particular embodiment, but, where applicable, are interchangeable and can be used in a selected embodiment, even if not specifically shown or described. The same may also be varied in many ways. Such variations are not to be regarded as a departure from the disclosure, and all such modifications are intended to be included within the scope of the disclosure. 

What is claimed is:
 1. An instrument for internal bone fracture fixation comprising: a first elongated shaft having a first distal portion; and a first patient-specific bone holder coupled to the first distal portion, the first bone holder having a three-dimensional curved and patient-specific bone engagement surface designed during a preoperative plan based on a medical scan of a patient and configured to match as an inverse surface to an outer surface of a first bone fragment of a fractured bone of the patient.
 2. The instrument of claim 1, wherein the first bone holder is removably couplable to the distal portion of the first shaft.
 3. The instrument of claim 2, further comprising a second bone holder removably couplable to the distal portion of the first shaft, the second bone holder having a three-dimensional curved and patient-specific bone engagement surface designed during a preoperative plan based on a medical scan to match as a inverse surface to an outer surface of a second bone portion of the patient in only one position.
 4. The instrument of claim 3, wherein the second bone portion includes a second bone fragment.
 5. The instrument of claim 3, wherein the first bone fragment and second bone portion are not contiguous.
 6. The instrument of claim 1, wherein the first bone holder is fixedly coupled to the distal portion of the shaft.
 7. The instrument of claim 1, wherein the first bone fragment includes a plurality of adjacent bone fragments.
 8. The instrument of claim 1, wherein the distal portion of the first shaft is connected to a first arm telescopically coupled to the first shaft.
 9. The instrument of claim 1, wherein the first shaft is pivotably coupled to a second shaft for scissors-like motion.
 10. The instrument of claim 9, wherein the second shaft is coupled to a second patient-specific bone holder.
 11. The instrument of claim 10, wherein the second patient-specific bone holder is removably coupled to a distal portion of the second shaft.
 12. The instrument of claim 1, wherein the first patient-specific bone holder includes a plurality of holes for receiving pins for stabilizing the first bone fragment.
 13. The instrument of claim 1, further comprising a patient-specific implant having a bone-engagement surface designed during the preoperative plan based on a medical scan of the patient to match as a inverse surface to an outer surface of a bone portion of the patient in only one position.
 14. The instrument of claim 13, wherein the outer surface of the bone portion include the outer surface of the first bone fragment.
 15. The instrument of claim 13, wherein the outer surface of the bone portion includes a fractured surface.
 16. An instrument for internal bone fracture fixation comprising: a first elongated shaft having a first arm with a first distal portion; a first patient-specific bone holder coupled to the first distal portion, the first bone holder having a three-dimensional curved and patient-specific bone engagement surface designed during a preoperative plan based on a medical scan of a patient and configured to match as an inverse surface to an outer surface of a first bone fragment of a fractured bone of the patient in only one position; a second shaft having a second arm with a second distal portion, the second shaft pivotably coupled to the first shaft; and a second bone holder coupled to the second distal portion.
 17. The instrument of claim 16, wherein the second bone holder is patient-specific.
 18. The instrument of claim 16, wherein the first bone holder includes a plurality of holes for receiving fixation pins.
 19. The instrument of claim 16, wherein the first and second arms are curved.
 20. The instrument of claim 19, wherein the first and second arms are designed to have a patient-specific shape and size.
 21. The instrument of claim 16, wherein the first bone holder is removably coupled to the first distal portion.
 22. The instrument of claim 16, further comprising a locking member between the first and second shafts for locking the first and second shafts in a selected relative position.
 23. The instrument of claim 16, further comprising a stabilizer including a stabilizing shaft coupled to a pivot extension between the first and second shafts, the stabilizer having a stabilizing support engageable to a bone portion of the patient.
 24. The instrument of claim 16, further comprising a patient-specific implant having a bone-engagement surface designed during the preoperative plan based on a medical scan of the patient and configured to match as an inverse surface to an outer surface of a bone portion of the patient in only one position.
 25. The instrument of claim 24, wherein the outer surface of the bone portion include the outer surface of the first bone fragment.
 26. An instrument for internal bone fracture fixation, comprising: a single elongated arm having a distal end; a removable coupling connector extending from the distal end; and a patient-specific bone holder removably coupled to the removable coupling connector at the distal end, the bone holder having a three-dimensional curved and patient-specific bone engagement surface designed during a pre-operative plan based on a medical scan of a patient and configured to match as an inverse surface to an outer surface of a bone fragment of a fractured bone of the patient.
 27. The instrument of claim 26, wherein the removable coupling connection is a snap-fit connection having at least one protrusion detent at the distal end of the elongated arm and an extension extending from the bone holder having a bore to receive the at least one protrusion.
 28. The instrument of claim 26, further comprising an elongated shaft telescopically receiving the elongated arm, wherein the elongated arm can be telescopically adjusted relative to the elongated shaft.
 29. The instrument of claim 28, further comprising a stabilizing member slidably along the elongated shaft through a hole defined in the stabilizing member, the stabilizing member lockable at a desired position on the elongated shaft by a fastener, wherein the stabilizing member is configured for engaging the bone to stabilize the elongated shaft. 